CTR062830_-_Endorsements.pdf
PDF 1 MB Posted
- Attached to
- Master Agreement AZ|CTR062830
- Contract number
- CTR062830
- Issued by
- Arizona
About this file
This document is an Arizona Policy Changes Endorsement for an insurance policy issued by Philadelphia Indemnity Insurance Company to Arizona Youth Partnership Inc, located in Tucson, AZ. The policy change involves adding additional insured status for the State of Arizona and its Department of Economic Security, including its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees. The endorsement includes several specific additions such as a Waiver of Subrogation, Additional Insured status, and Primary and Non-Contributory coverage for Auto.
The policy is effective from 04/04/2024 to 03/01/2025, with no changes to be adjusted at audit. The endorsement includes a removal permit for covered property, allowing insurance coverage during property relocation for up to 10 days after the effective date. The policy change specifically adds forms such as CG2037 for Additional Insured - Owners, Lessees or Contractors for completed operations, and includes provisions for General Liability coverage. The issue date of the endorsement is 05/01/2024, and it is part of Policy Change Number 9 with Revision Number 9.
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Text version
POLICY NUMBER:
IL 12 09 08 23
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
IL 12 09 08 23 © Insurance Services Office, Inc., 2022 Page 1
ARIZONA POLICY CHANGES
Policy Change Number:
Policy Number: Company:
From: 12:01 AMPolicy Changes Effective:
To: 12:01 AM
At the named insured's mailing address shown below.
Named Insured: Authorized Representative:
Named Insured's Mailing Address:
Coverage Parts Affected:
Changes
The above amendments result in a change in the premium as follows:
NO CHANGES TO BE ADJUSTED AT AUDIT ADDITIONAL PREMIUM
RETURN PREMIUM
{See Additional Page(s)}
Path ID
Revision No.:
Philadelphia Indemnity Insurance Company
PHPK2647728
PHPK2647728
Delta Insurance Agency Ltd
03/01/2025
Arizona Youth Partnership Inc
Tucson, AZ 85743-1538
04/04/2024
7575 W Twin Peaks Rd. Ste 165
Additional Interests
17552091
X
IL 12 09 08 23 © Insurance Services Office, Inc., 2022
ARIZONA POLICY CHANGES ENDORSEMENT DESCRIPTION
REMOVAL PERMIT
If this policy includes the Commercial Property Coverage Part, the following applies with respect to such Coverage Part(s):
If Covered Property is removed to a new location that is described on this Policy Change, you may extend this insurance to include that Covered Property at each location during the removal. Coverage at each location will apply in the proportion that the value at each location bears to the value of all Covered Property being removed. This permit applies up to 10 days after the effective date of this Policy Change; after that, this insurance does not apply at the previous location.
Countersignature Of Authorized Representative Name:
Title:
Signature:
Date:
05/01/2024Issue Date:
Added:
Form CG2037- Additional Insured - Owners, Lessees or Contractors - Completed operations With respects to Additional Insured The State of Arizona and Department of Economic Security
The State of Arizona, its departments, agencies, boards, commissions, universities,officers, officials, agents and employees
1. ADD CA 0444, 10/2013, Waiver of Subrogation Description: The State of Arizona, its departments, agencies, boards, commissions, universities,officers, officials, Agents and employees.
2. ADD Ca2048, 10/2013, Additional Insured Description: The State of Arizona, its departments, agencies, boards, commissions, universities,officers, Officials, agents and employees.
3. ADD Primary and Non-Contributory for Auto.
GENERAL LIABILITY - This endorsement should be in process of corrections as there was missing info (last two Agents and employees) were missing from the previous endorsement.
Line of Business: General Liability Form Information
4. ADD CG2037, AI Completed operation
In consideration of the premium reflected, the policy is amended as indicated below:
IL 12 09 08 23 © Insurance Services Office, Inc., 2022
ARIZONA POLICY CHANGES ENDORSEMENT DESCRIPTION
REMOVAL PERMIT
If this policy includes the Commercial Property Coverage Part, the following applies with respect to such Coverage Part(s):
If Covered Property is removed to a new location that is described on this Policy Change, you may extend this insurance to include that Covered Property at each location during the removal. Coverage at each location will apply in the proportion that the value at each location bears to the value of all Covered Property being removed. This permit applies up to 10 days after the effective date of this Policy Change; after that, this insurance does not apply at the previous location.
Countersignature Of Authorized Representative Name:
Title:
Signature:
Date:
05/01/2024Issue Date:
Description: Additional Insured for completed operations
Per Attached P# 17486218
(Continued)
PI-MANU-1 (09/06)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
All other terms and conditions of this Policy remain unchanged.
| Insurance Policy |
| Arizona Policy Changes (Part 1) |
| Arizona Policy Changes (Part 2) |
| Manuscript Endorsement |
File details come from the government source that posted it. Updated .